Category Archives: News

Save the Menisci: Meniscal Root Tears

The menisci are c-shaped, rubber-like cartilage discs that reside inside the knee joint.  There are two menisci in every knee, one on the inner side (medial meniscus) and one on the outer side (lateral meniscus). Their function is to increase surface area for weight transmission between the cartilage on the ends of the bone, which decreases pressure between the ends of the bone and adds to stability of the joint.  Both the medial and lateral menisci have stout attachments at the front and back of the tibia, these attachments are often called “roots”. These meniscal roots are important because they hold the meniscus in place to provide stability to the entire meniscus. The stability is obtained by a functional circumferential hoop which the C-shape obtains with attaching at the roots. This functional hoop stability prevents the meniscus from extruding out when pressure is exerted across the joint, effectively keeping the meniscus in place between the two bones.

Meniscus tears can occur in a number of different shapes and scenarios. They can occur as a result of accumulative wear and tear of the joint or as the result of an injury. Sometimes, wear and tear changes in the meniscus can be subtle until an injury event occurs and the scenario is worsened drastically. Tears of the meniscus root are especially concerning because they compromise the functional hoop property of the meniscus, rendering the meniscus non-functional. When there is a tear of the meniscal root the studies have suggested that pressure upon the cartilage is increased to levels similar to having no meniscus at all. This can subsequently cause early degeneration of the joint.

Meniscus root tears are often seen in two groups of patients:

  • The first group consists of young adults and athletes who sustain a root tear with a severe knee injury. This may include injury to the ACL, PCL or other ligaments of the knee. Failure to repair the meniscal root in these circumstances can lead to the development of early osteoarthritis, failure of a ligament reconstruction graft and other potential problems with age.
  • The second group of patients are middle-aged adults. In this population, the injury is “acute on chronic”. There are degenerative changes at the root and then the meniscal root becomes non-functional with an injury event. A sudden knee bending event accompanied by a “pop” in the back of the knee, is often described by patients who have had a root tear. A sudden deep squat or twist are also sometimes described. In this group of patients, rapid development of osteoarthritis can occur.

Symptoms

The primary symptoms of a meniscus root tear include pain on the inside or outside of the knee with mechanical symptoms.  Certain activities such as pivoting, running, climbing, or even getting up from a chair may produce symptoms including popping and catching.  Patients may hear or feel a clicking sound with movement, and the knee may be tender to the touch for some in specific locations.

Figure 1, Coronal view of normal meniscal root

Diagnosis

While an X-ray will not show meniscal damage, it is necessary to evaluate the overall health of the knee joint, as subtle changes on X-rays are common and help to guide treatment. Although a history, physical exam and x-ray are important in diagnosis, an MRI is important to visualize the meniscal root (Figure 1). These root tears can be very difficult to identify on MRI but is most often diagnosed when a “ghost sign” is seen. Meniscal root tears can be seen on coronal, axial and sagittal MRI views. On the sagittal view, as seen in figure 3, there is a ghost sign which is indicative of a meniscal root tear. A normal, healthy meniscus should look like a dark black triangle. On the coronal view, as seen in figure 2, there is a tear of the meniscal root.

Figure 2, Coronal View with “Ghost Sign”

 

Figure 3, Sagittal View with “Ghost Sign”

Surgical Treatment

Treatment of meniscal root tears can be very difficult, especially in older patients. In older patients, repair can be difficult as tears are not commonly diagnosed until progression of arthritis is more severe. In younger patients, repair is much easier due to decreased prevalence of joint degeneration.

Figure 4, Normal Meniscal Root

An arthroscopic approach is utilized to repair the meniscal root.  Once access is made into the knee, Dr. Anz will visualize the meniscal root (Figure 4). A device is used to pull on the root to confirm the presence of a tear. After a tear is confirmed, Dr. Anz will use a guide to drill a tunnel at the anatomic site of the original root. (Figure 5) This tunnel will become the new home for the torn meniscal root. Sutures will be passed through the torn portion (Figure 6) of the meniscus and shuttled down into the tunnel previously drilled. Once the sutures have been pulled into the tunnel, Dr. Anz will visualize the meniscus and tighten the sutures and secure them with a suture anchor.

Figure 5, Drill bit coming up from root attachment
Figure 6, Sutures passed through the root repair

Post-Operative

After surgery, the patient will be non-weight bearing for 6 weeks to allow for healing of the repair. Physical therapy may be initiated the day after surgery. Range of motion at the knee is limited to 90 degrees of flexion for the first weeks in order to prevent excess stress on the repair. Six weeks after surgery a partial protective weight bearing program is initiated to slowly wean from the crutches. Patients should avoid impact activities, deep squats, and lifting in a deep squat for a minimum of 4 months after surgery to protect the meniscus root repair.

For more information on meniscus injuries, or to learn more about the surgical treatments for meniscus tears offered by Dr. Adam Anz, Orthopedic Surgeon/Sports Medicine Specialist, please contact our office

The Biology of ACL Healing: The Wild Card of Recovery

Ligamentization – The Wild Card

One of the most critical steps in ACL reconstruction is grafting a tendon into the knee to replace the damaged ACL. Following surgery, the graft not only has to heal tightly in its new position but also transition structurally from a functioning tendon to a functioning ligament—a process known as ligamentization. Believe it or not, this process takes time! Microscopic studies, in which physicians have taken small samples of healing ligaments following ACL reconstruction to determine their rate of ligamentization, suggest that this process can take anywhere from 6 to 24 months.

Continue reading The Biology of ACL Healing: The Wild Card of Recovery

When is an athlete ready for contact sports after ACL surgery?

Returning to Sport Following ACL Reconstruction

After ACL reconstruction, the most common question is also the most difficult to answer: “When will I be ready to go back to ___?” In short, there is no blanket answer; there are many factors that determine when the time is right for a patient to return to sport. These factors are physical, biologic and psychological in nature and they affect each patient’s recovery in a unique way. At the end of the day, return to sport is a decision that needs to be made on a patient-to-patient basis, weighing the benefits of continued rest and rehabilitation with the risks and benefits of returning to sport.

Continue reading When is an athlete ready for contact sports after ACL surgery?

Biceps Anatomy Study

Thank you to Eric Branch for his help with our recent study on the biceps femoris. It was published last month in the Orthopaedic Journal of Sports Medicine. This tendon injury can accompany anterior cruciate ligament injuries in football players. The more we learn about it the better we will be at our repairs/reconstructions. In this study we learned exactly where the tendon inserts on the tibia and fibula and its association with the anterolateral ligament.

http://www.ncbi.nlm.nih.gov/pubmed/26535398

Meniscus Repair Paper Published in The American Journal of Sports Medicine

Last month a biomechanical study which we completed at the Andrews Research and Education Foundation was published in the American Journal of Sports Medicine.

9.cover

http://ajs.sagepub.com/content/43/9/2270.abstract

The study evaluated the repair strengths of four meniscus repair methods for radial meniscus tears. Radial meniscus tears can accompany anterior cruciate ligament (ACL) tears, particularly radial tears of the lateral meniscus. A new instrument known as the Ceterix Novostitch was evaluated.

http://www.ceterix.com

Figure 4

Figure 1

The study determined that complex patterns of suture repair are stronger than simple patterns.

11th Annual Middle East Orthopaedics Conference

Dr. Anz was an invited faculty member of the 11th Annual Middle East Orthopaedics Conference in Dubai, UAE.  Chaired by Dr. William Murrell, this meeting involved faculty from all over the world including Dr Charles Brown from Abu Dhabi , Prof Brian Cole from the Rush Medical Center, Prof Mandeep Dhillon from Chandigarh, India, Dr Elizaveta Kon and Prof Maurilio Marcacci from Bologna Italy, Prof Nicola Maffulli from The Royal London Hospital, Prof Parag Sanchetti from Maharashtra, India,  Prof Ullrich Schneider from Rottach-Ergen, Germany, and Dr Clarence Shields of the Kerlen-Jobe Clinic.  

panel 2Dr. Anz gave a lecture on Peripheral Blood Stem Cells for Cartilage Regeneration as well as led a roundtable discussion session entitled: Primetime for cartilage and biologics transition to a new paradigm.Roundtable discussion: Primetime for cartilage and biologics transition to a new paradigm.

See more at: http://www.arabhealthonline.com/conferences/medical-conferences/orthopaedics-conference/#sthash.X5cz7l6Y.dpuf

 

AAOS Now Interview

Dr. Anz was interviewed regarding his JAAOS article examining the application of biologics for the rotator cuff, meniscus, and cartilage by AAOS Now, the official member newsmagazine of the American Academy of Orthopaedic Surgeons.

 

Maureen Leahy asks:

Biologics have been used for some time in medicine. What is their role in orthopaedics?

Dr. Anz:

In my opinion, biologics represent the next frontier in orthopaedics.  During the past 30 years, particularly in sports medicine, the focus has been on the use of the arthroscope, which revolutionized how we performed treatments.  I believe biologics will revolutionize the next 30 years.  

Maureen Leahy: 

Are each of these biologic technologies equally important?

Dr. Anz:

I don’t think any one of them is more important or warrants more study than the others.  PRP, BMA, and stem cells are like arrows in a quiver.  In some instances, PRP will be the right arrow to use; in a different situation, BMA might be more appropriate.  From a regulatory standpoint, PRP and BMA are the arrows we can use right now.  The FDA has made it clear that it is going to take a tough stance on stem cells, no matter what the harvest site-and rightfully so. It will be exciting, however, once we can use them. 

If you would like to see the interview in its entirety, go to:

http://www.aaos.org/news/aaosnow/feb14/clinical9.asp

Biologics in Rotator Cuff, Meniscus, Cartilage and Osteoarthritis Article

Drs. Anz, Hackel, Nilssen, and Andrews authored an article regarding the application of biologics in sports medicine which was published this month in the Journal of the American Academy of Orthopaedic Surgery.  The article entitled “Application of biologics in the treatment of the rotator cuff, meniscus, cartilage, and osteoarthritis” reviewed the current status of the use of platelet rich plasma, bone marrow aspirate, and stem cells within sports medicine.

what-can-stem-cells-doThere is evidence that these technologies are going to influence the way that orthopaedic surgeons practice medicine, and work at the Andrews Institute is focusing on leading the way but also producing proof that these methods are making a difference in the lives of our patients.

 

If you have questions about platelet rich plasma, bone marrow aspirate, or stem cells please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.

Figure 11-Chondrogenesis Theory.112